Take
Home Message: Patients with shoulder impingement syndrome (SIS) who underwent a
thoracic spine manipulation (TSM) had an immediate decrease in symptoms; however,
no differences in scapular kinematics were identified.

Shoulder impingement syndrome (SIS) is a common condition associated
with abnormal scapular kinematics (i.e., increased scapular internal rotation
and decreased upward rotation and posterior tilt). This condition is often treated using
rehabilitation exercises and sometimes manual therapy. Specifically, high-velocity low amplitude
(thrust) thoracic spine manipulation (TSM) is a manual therapy technique that
has been investigated for treating shoulder conditions. However, the contribution and effectiveness
of TSM for treatment of SIS has not been well-studied. Therefore, Haik and colleagues conducted a randomized
controlled study to assess the immediate effects of TSM on pain and scapular movement
during elevation and lowering of the arm in individuals with SIS. Fifty participants
with SIS (average age 31.8 years) and 47 asymptomatic participants (average age
25.8 years) were randomized into 2 groups: manipulation or sham treatment. For the sham treatment, a therapist applied
all the same forces as done for the thrust-manipulation, but a thrust was not
used. Scapular movements were analyzed
during elevation and lowering of the arm in the sagittal plane. The authors used pain scores (numeric pain rating scale) to assess shoulder pain during arm
movement pre- and post-intervention. For
those in the SIS group, shoulder pain was immediately reduced after TSM and
sham interventions. Despite no
differences in the average pain improvement between the treatment groups more participants
had pain relief after TSM (~60%) then after sham intervention (~36%). For some scapular movements, the authors
observed subtle differences between pre- and post-intervention; however, the small
magnitude of the differences failed to meet a level of clinical importance,
defined based on existing research.

The clinical rationale
for TSM is related to the concept of regional interdependence proposed by Wainner et al.
He suggested that unrelated impairments in an anatomical region may
contribute to, or be associated with, the patient’s primary complaints. For example, alterations in the thoracic
spine and ribs may contribute to shoulder impingement symptoms. The authors demonstrated that shoulder pain
in individuals with SIS is immediately decreased after a TSM, supporting this
concept of regional interdependence.
However, there was not a clinically-important difference in scapular movements
following TSM. This suggests that TSM provides little to no adjustment in
biomechanical motion of the scapula. Therefore,
the mechanism by which this pain relief is achieved is unclear. It is possible that neurophysiological
effects of joint manipulation may alter sensory information (e.g., pain
processing, motor control) from the shoulder to the central nervous
system. Future studies should work to
identify the biologic and mechanical mechanisms by which spinal manipulation
techniques decrease pain in participants with SIS. Additionally, the long-term effects of spinal
manipulations should also be characterized.
Findings from this study raise additional questions in our understanding
of manual therapies and highlight the importance of considering regional
interdependence when evaluating and treating shoulder conditions. This study suggests that the use of TSM may
be a useful technique to manage pain in patients with SIS.

Questions
for Discussion: Based on results from this study, would you employ thoracic
spinal manipulations to manage pain associated with SIS? Do you think TSM could have long-term
benefits in treating SIS?

4
comments:

The question that I have is what is the mechanism that TSM resolves to create the reduction in pain? Is it that the mob restores adequate function to the scapular musculature? Or is it that these individuals have created thoracic accommodations that are blocked until returned to a normal thoracic movement pattern?

Thanks for your comment. Unfortunately, this study was unable to answer these mechanistic questions. However, it did demonstrate that restoration of scapular kinematics is not the mechanism by which pain is relieved. I think it may only be temporary pain relief associated with an alteration in sensory information from the shoulder to the central nervous system following the manipulation. However, this definitely warrants future studies.

After further evaluation of the article, it appears that the benefits of Thoracic Thrust Manipulation (TSM) are limited. Data analysis of the p-value, effect size, and confidence intervals helps support the limits of TSM. The p-value did show statistical significance in the scapular upward rotation manipulation impingement, scapular upward rotation manipulation asymptomatic, scapular upward rotation sham asymptomatic group and scapular tilt manipulation asymptomatic groups. P-value also showed statistical significance in pain modulation. Despite the p-values, the effect size did not show statistical significance. The confidence intervals also did not indicate statistical significance. Results of the study shows little evidence of pain modulation TSM on shoulder impingement syndrome (SIS). Based on the study setup focusing solely on TSM for pain modulation and correction of scapular kinematics, I would not solely utilize TSM for pain modulation. The holistic approach of targeting the thoracic spine for relieving scapular pain does seem to be appropriate, but scapular mobilization should also be considered. In order for TSM to have long-term benefits, scapular mobilization along with therapeutic exercises for the scapular stabilizers should be implemented for a comprehensive rehabilitative approach. Correction of the scapular kinematics should drive the therapeutic approach, not just pain modulation. Future research should look at techniques that help increase the scapular kinematics of posterior tilt, scapular internal rotation and upward rotation to alleviate SIS.

Alexander,you are are correct the effect of TSM on pain was small although it is an interesting finding that it was not related with changes in scapular kinematics. It might be that scapular kinematics is not the sole source of the pain. I agree that based on this study I may try TSM but pair it with my traditional individualized rehab program.

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